The evidence grading system for clinical practice recommendations (A through C, E) is defined at the end of the "Major Recommendations" field.
Diabetes Care in Specific Settings
Diabetes Care in the Hospital
- All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record. (E)
- All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)
- Goals for blood glucose levels:
- Critically ill patients: blood glucose levels should be kept as close to 110 mg/dL (6.1 mmol/L) as possible and generally <140 mg/dL (7.8 mmol/L). (A) These patients require intravenous (IV) insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risks for severe hypoglycemia. (E)
- Non–critically ill patients: there is no clear evidence for specific blood glucose goals. Since cohort data suggest that outcomes are better in hospitalized patients with fasting glucose <126 mg/dL and all random glucoses <180 to 200, these goals are reasonable if they can be safely achieved. Insulin is the preferred drug to treat hyperglycemia in most cases. (E)
- Due to concerns regarding the risk of hypoglycemia, some institutions may consider these blood glucose levels to be overly aggressive for initial targets. Through quality improvement, glycemic goals should systematically be reduced to the recommended levels. (E)
- Scheduled prandial insulin doses should be given in relation to meals and should be adjusted according to point-of-care glucose levels. The traditional sliding-scale insulin regimens are ineffective as monotherapy and are not recommended. (C)
- Using correction dose or "supplemental" insulin to correct premeal hyperglycemia in addition to scheduled prandial and basal insulin is recommended. (E)
- Glucose monitoring with orders for correction insulin should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoids therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications. (B) If hyperglycemia is documented and persistent, initiation of basal/bolus insulin therapy may be necessary. Such patients should be treated to the same glycemic goals as patients with known diabetes. (E)
- A plan for treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be tracked. (E)
- All patients with diabetes admitted to the hospital should have an A1C obtained if the result of testing in the previous 2 to 3 months is not available. (E)
- A diabetes education plan including "survival skills education" and follow-up should be developed for each patient. (E)
- Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge. (E)
Diabetes Care in the School and Day Care Setting
- An individualized diabetes medical management plan (DMMP) should be developed by the parent/guardian and the student's diabetes health care team. (E)
- An adequate number of school personnel should be trained in the necessary diabetes procedures (including monitoring of blood glucose levels and administration of insulin and glucagon) and in the appropriate response to high and low blood glucose levels. These school personnel need not be health care professionals. (E)
- As specified in the DMMP and as developmentally appropriate, the student with diabetes should have immediate access to diabetes supplies at all times, should be permitted to monitor his or her blood glucose level, and should be able to take appropriate action to treat hypoglycemia in the classroom or anywhere the student may be in conjunction with a school activity. (E)
Diabetes Care at Diabetes Camps
- Each camper should have a standardized medical form completed by his/her family and the physician managing the diabetes. (E)
- Camp medical staff should be led by a physician with expertise in managing type 1 and type 2 diabetes and includes nurses (including diabetes educators and diabetes clinical nurse specialists) and registered dietitians with expertise in diabetes. (E)
- All camp staff, including physicians, nurses, dietitians, and volunteers, should undergo background testing to ensure appropriateness in working with children. (E)
Diabetes Management in Correctional Institutions
- Correctional staff should be trained in the recognition, treatment, and appropriate referral for hypo- and hyperglycemia, including serious metabolic decompensation. (E)
- Patients with a diagnosis of diabetes should have a complete medical history and physical examination by a licensed health care provider with prescriptive authority in a timely manner upon entry. Insulin-treated patients should have a capillary blood glucose (CBG) determination within 1 to 2 hours of arrival. Staff should identify patients with type 1 diabetes who are at high risk for diabetic ketoacidosis (DKA) with omission of insulin. (E)
- Medications and medical nutrition therapy (MNT) should be continued without interruption upon entry into the correctional environment. (E)
- In the correctional setting, policies and procedures should enable CBG monitoring to occur at the frequency necessitated by the patient's glycemic control and diabetes regimen, and should require staff to notify a physician of all CBG results outside of a specified range, as determined by the treating physician. (E)
- For all inter-institutional transfers, a medical transfer summary should be transferred with the patient, and diabetes supplies and medication should accompany the patient. (E)
- Correctional staff should begin discharge planning with adequate lead time to insure continuity of care and facilitate entry into community diabetes care. (E)
For more information, see the National Guideline Clearinghouse (NGC) summary of the American Diabetes Association (ADA) guideline Diabetes Management in Correctional Institutions.
Emergency and Disaster Preparedness
- People with diabetes should maintain a disaster kit that includes items important to their diabetes self-management and continuing medical care. (E)
- The kit should be reviewed and replenished at least twice yearly. (E)
Definitions:
American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations
A
Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:
- Evidence from a well-conducted multicenter trial
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
- Compelling non-experimental evidence (i.e., "all or none" rule developed by the Center for Evidence Based Medicine at Oxford*)
Supportive evidence from well-conducted randomized, controlled trials that are adequately powered, including:
- Evidence from a well-conducted trial at one or more institutions
- Evidence from a meta-analysis that incorporated quality ratings in the analysis
*
Either all patients died before therapy and at least some survived with therapy, or some patients died without therapy and none died with therapy. Example: use of insulin in the treatment of diabetic ketoacidosis.
B
Supportive evidence from well-conducted cohort studies, including:
- Evidence from a well-conducted prospective cohort study or registry
- Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C
Supportive evidence from poorly controlled or uncontrolled studies, including:
- Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
- Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)
- Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E
Expert consensus or clinical experience
